The board room at Maine Medical Center filled with members of the Hospital Incident Command System (HICS) during their daily meeting on March 12. Brianna Soukup/Staff Photographer

Just hours before Maine reported its first coronavirus case, about 50 Maine Medical Center doctors, nurses, administrators and infectious disease specialists crammed around a large conference table on the second floor of a room reserved for disaster planning.

On the wall was a giant monitor displaying a map of the world, with ominous red circles of varying sizes indicating hot zones of the virus – a new respiratory disease the world has never seen before and for which there is not a vaccine.

The Maine Med staff knew this was not a typical planning meeting, not a drill or some academic exercise in disease prevention. They understood it was the beginning of something new and dangerous and they were being summoned to help plan for its arrival and to help those who would become infected.

What many didn’t know was that within days of their meeting, the spread of the new virus would dramatically alter society.

“The sense of anxiety is going up,” says Jeff Sanders, president of the nearly 7,000-employee hospital. “I feel it. We all feel it.”

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The meeting was called Hospital Incident Command System – HICS for short – and hospitals around Maine and the country convene similar meetings when preparing or responding to a disaster, like a blizzard, flood or windstorm.

Or a pandemic.

The mood was tense but friendly. Some had pained expressions. It was 10 a.m. on Thursday, March 12. In two hours, the Maine Center for Disease Control and Prevention would report its first case.

The Portland Press Herald/Maine Sunday Telegram was given behind the scenes access for two days to learn how the hospital prepared for this new public health emergency. Within a week of that daily meeting, the Maine CDC reported 52 known coronavirus cases, Gov. Janet Mills would declare a civil emergency and much of the country’s nonessential services, businesses and schools would shut down. As of Saturday the number of confirmed cases in Maine had grown to 70.

Even though Maine had yet to have a confirmed case, the disaster planners were working as if the virus had already arrived. The illuminated map on the wall was an impending reminder of what was to come.

Martin Coyne, director of warehouse operations, speaks at the daily Hospital Incident Command Systems (HICS) meeting at Maine Medical Center on March 12. Maine Med activated HICS, which is deployed before and during emergencies, the previous week because of the impending coronavirus pandemic. Brianna Soukup/Staff Photographer

On that day, there were 127,863 cases worldwide and 1,323 deaths. Italy was reporting its hospitals were being overrun. By Saturday, there were 306,677 cases and at least 13,017 deaths, with 4,825 deaths in Italy. The United States was reporting 25,896 cases with 316 deaths as of Saturday.

Jennifer McCarthy, chief operating officer of Maine Med, ran the meeting wearing a yellow and white safety vest that said “Incident Commander” on the back.

The chief operating officer of Maine Medical Center, Jennifer McCarthy, presides over the daily Hospital Incident Command System (HICS) meeting. Brianna Soukup/Staff Photographer

Behind her, handwritten on a whiteboard, were the words Preparation Phase 1 and Community Spread Phase 2.

“We are moving into Phase 2,” she reports.

McCarthy commandeers the planning at a rapid-fire pace, quickly moving from topic to topic.

“How are we with supplies?” she says. Visitation policy. Postponing elective surgeries. Canceling all community meetings. Limiting group meetings.

That meeting size limit affects the HICS itself. By March 13, the group is down to 25 people . The hospital also begins leaning more on videoconferencing for its regularly scheduled meetings.

Decisions are being made not just for Maine Med, but also for MaineHealth, the parent company that includes eight other Maine hospitals, 22,000 employees and numerous outpatient clinics and primary care centers.

Dr. Joel Botler, senior vice president and chief medical officer at Maine Med, says  employees  – regardless of where they worked in the MaineHealth system – should be prepared to work at the Portland hospital if needed. Perhaps pediatricians would be called upon to help care for adult patients.

“The likelihood of pediatricians working to care for our adult patients is low, but we have to be prepared,” Botler warns.

Botler says critical care beds – which currently stand at 54 – could be potentially doubled or more as the hospital looks to convert other spaces to care for patients with COVID-19.

“We plan to increase that number significantly,” Botler said.

Across the nation, there’s a critical shortage of hospital beds to care for coronavirus patients if there’s a sudden influx of patients. The United States has about 925,000 hospital beds, but many are occupied, and Harvard Global Health Institute reports that – depending on the peak of  the virus – hospitals may need to double total capacity.

When converting the space, the hospital will work to make the rooms “negative pressure,” which prevents cross-contamination to other rooms.

The hospital recently purchased 20 new ventilators – they now have 80 in total – to help if Maine Med becomes flooded with coronavirus patients.  Statewide, Maine has 291 hospital ventilators, and the Maine CDC is asking the federal government for more to prepare for a potential wave of patients. National health experts were sounding the alarm that there are not enough hospital ventilators – currently about 100,000 across the country – to meet an expected surge in demand. Estimates of how many ventilators are needed vary depending whether social distancing efforts to “flatten the curve” are effective.

In Italy, doctors were having to ration ventilators, making difficult choices about who lived and who died.

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In a closet-sized room tucked away in the original building of the sprawling 637-bed Maine Med sits Dr. August Valenti.

In many ways, this is the epicenter of hospital’s response to the coronavirus. No one is in more demand at Maine Med than Valenti, a gregarious, silver-haired infectious disease specialist.

Dr. August Valenti, Maine Medical Center’s epidemiologist, in his office.

“Augie,” as he’s called affectionately, is the hospital’s epidemiologist and director of the special infectious diseases program.

Sitting ramrod-straight in his office – a bare-bones, claustrophobia-inducing space – he takes calls from staff and sends emails to the Maine CDC.

Behind him is a whiteboard with a quote from the French philosopher Voltaire: “Opinion has caused more trouble on this little earth than plagues or earthquakes.”

He turns serious and speaks in a soft tone when discussing the worldwide pandemic and how it might affect Maine.

“The impact could be enormous,” Valenti says, gazing out the fifth-floor window. A sudden surge of coronavirus patients – 50 or more – would put a huge strain on hospital services.

“We have to do whatever we can do to protect employees, patients and visitors. We have adequate (pandemic) supplies at our hospital. But we know supplies can be depleted rather quickly.”

The coronavirus that causes COVID 19 is “one of the most challenging viruses we have seen.”

Valenti has worked here since 1984 and has been putting in 70-80 hour weeks getting the hospital ready for the virus.

“With the flu, we know that disease, we have vaccines, we have treatment. We don’t have any of that yet for COVID-19,” Valenti says.

With that, Valenti unfolds his lanky frame, squeezes out of his office and walks briskly down the hallways.

He presses elevator buttons with the sleeve of his white coat, ready to do his rounds.

“This is known as the ‘Valenti technique,'” he says, with a grin wider than his bow tie.

Valenti spends much of his time on the phone, answering texts and emails from a number of people who lean on his expertise and advice.

Dr. August Valenti, Maine Medical Center’s epidemiologist, walks on his rounds. Brianna Soukup/Staff Photographer

But some tasks should be done in person, and on this day Valenti heads over to “Bean 5,” a wing of the hospital where a patient with possible coronavirus was staying. The patient – a man in his 50s – was hospitalized for another condition and had a “sudden onset” of symptoms similar to coronavirus.

Valenti meets with Marilyn Flanders, director of nursing for Bean 5, mostly peppering her with questions, making sure she had the supplies and resources needed to care for the patient.

“Has the specimen been sent?” Valenti asks – referring to a coronavirus test – and Flanders nods “yes.”

A nurse – who did not wish to be identified – emerges from the patient’s room, decked out in protective equipment that was not quite a full infectious disease suit, but close to it. Called PAPR – which stands for Powered Air Purifying Respirators – she wears a gown, hood, plastic visor, shoe covers that come up to her shins, and gloves. The respirator hums as she begins taking off the items.

She removes the gear in a precise order. First the shoe covers, then the gloves, gown and PAPR. Then she sterilizes the hood and hose with a disinfecting wipe. Gloves and booties go into the trash. The gown is tossed into a linen basket.

A nurse begins the procedure of doffing, or removing, her personal protective equipment (PPE), after leaving the room of a patient who is being tested for the coronavirus. Brianna Soukup/Staff Photographer

Matthew Paré, the charge nurse who also went into the patient’s room, says nurses have to do the procedure every time, and they have to go into the room many times per shift.

Based on the evidence that he had seen, Valenti says that the patient would test negative for coronavirus, and by Thursday the test came back negative. The patient was cleared of having the virus, and those caring for him no longer had to wear infectious disease equipment.

Valenti says many results will be negative, and that’s helpful for the hospital staff. Statewide, there were more than 2,000 negative tests compared to 56 positive by March 20.

“It’s OK if it’s negative. When you practice, you learn your vulnerabilities,” Valenti said.

Eight days later, Maine Med would have cared for five confirmed coronavirus patients.

Charge nurse Matthew Paré puts on personal protective equipment (PPE) before entering the room of a patient who is being tested for coronavirus.The patient’s test later came back negative. Quicker test results for the hospital mean they use less protective gear. Brianna Soukup/Staff Photographer

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Throughout many parts of Maine Med, posters are hung up on doorways to remind employees of how to don and doff the personal protective equipment.

Nurse Melissa Fairfield instructs a group of about a dozen doctors and nurses on the proper procedures during a recent training session.

These are precise instructions. Done in the wrong order, or touching things the wrong way can diminish efforts to reduce the spread of infection.

“We’re not trying to cause a panic, just need people to disinfect when you can,” Fairfield says. While shoe covers and gloves were disposable, the plastic visors, hoods and respirators could be used again, so they are to be wiped down with disinfecting wipes.

Nurse Melissa Fairfield leads the Special Infectious Disease Team (SIDT) in a refresher training of personal protective equipment. Brianna Soukup/Staff Photographer

Dr. Andreas Thyssen, a pediatrician at Maine Med’s Barbara Bush Children’s Hospital, says he has received the training previously, but practicing how to do it is necessary.

“We have a really good procedure in place. It’s easy to be lax, but with the training we do we are always reminded,” Thyssen says. “It’s similar to preparing for flu, but we’ve beefed everything up a bit.”

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About a month ago, scientists at MaineHealth’s NorDx Laboratories saw what was happening in China and prepared for the coronavirus’s arrival in the United States.

Dr. Robert Carlson, the laboratory’s medical director, says the staff felt a sense of urgency and began placing orders for supplies so that NorDx could make its own coronavirus test.

“The capacity of the CDC is limited, so we knew we had a chance to help,” Carlson says. “It’s in the early and middle parts of the outbreak that it’s really important to have enough testing.”

The United States has not had enough testing capacity, and public health experts say that vulnerability is worsening the problem. In contrast, South Korea had ramped up its testing capabilities, performing 10,000 or more tests daily, and has largely contained the virus in that country.

Dr. Hayley Weber, director of molecular biology at NorDx Laboratories, far right, talks with employees on March 12. NorDx started processing coronavirus tests early in the week and by Thursday they were able to get a result in about four hours. Brianna Soukup/Staff Photographer

NorDx completed all the regulatory steps and by March 9, the lab started testing, doubling or more the Maine CDC’s testing capacity. Carlson says the lab could potentially perform thousands of tests and have them done quickly.

“Our goal is if we get a sample at 8 a.m., we can get the results by noon,” he says. “We have enough tests to keep up with anticipated demand – for now.” Eight days after Carlson made that statement, the Maine CDC was reporting that statewide testing capacity was running low, and the agency requested more testing kits from the federal government.

Through March 20, Maine had performed 2,320 tests, second only to Massachusetts among the New England states.

When Maine relied exclusively on the U.S. Centers for Disease Control and Prevention for testing, it took three to five days to get results. The Maine CDC lab is turning around test results within 48 hours, and NorDx is producing results in less than a day.

The test consists of two swabs, one to take a sample from the nasal passage, and the other from the back of the throat. Once the samples are collected, they are brought to a NorDx machine that employs RNA extraction to detect the virus if it is present and amplifies it so scientists can see its presence.

“We are looking for the specific genetic fingerprints of the virus,” Carlson says.

Hayley Webber, director of molecular testing for NorDx, explains that the machine uses fluorescent tags on the RNA – ribonucleic acid – the genetic building blocks of the virus.

“If the patient has coronavirus, the sample will light up,” Webber says.

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At a location that the Press Herald/Sunday Telegram agreed not to release publicly is a warehouse the size of three basketball courts where boxes are stacked as high as a two-story house.

This is the pandemic supply warehouse. It’s an essential facility housing some of the hospital’s most important weapons in its fight against the invisible virus: Respirators, gowns, shoe covers,, visors, gloves – equipment needed to protect workers and patients.

John Swiger, safety manager at Maine Medical Center, walks through the pandemic supply warehouse. Brianna Soukup/Staff Photographer

The items stockpiled here can be used for any emergency that would threaten hospital supplies – from a pandemic to an extended blizzard or flooding.

“We have supplies in case of an emergency of any type and we are prepared to pull anything from this warehouse at a moment’s notice,” says Martin Coyne, director of warehouse operations.

When Maine Med needed extra shoe covers to treat patients who were suspected of having coronavirus – and who later tested negative – the warehouse shipped two boxes.

John Swiger, Maine Medical Center’s safety manager, says if an emergency of some kind prevented the hospital from getting supplies from its usual sources, it could still operate for 96 hours only using material from the warehouse.

“There’s never enough from an emergency preparedness standpoint. I could have 10 warehouses” he says.

When coronavirus started becoming a concern in China late last year, Swiger was able to secure 2,000 visors and hoods, which will help doctors and nurses remain safe from infections while treating coronavirus patients.

“It’s difficult to stock up once an epidemic has started,” Swiger says. “You can’t just place an order. You have to justify everything. Every hospital in the country is trying to get the same supplies.”

Many of the supplies are holdovers from the H1N1 flu epidemic from 2009. The warehouse has thousands of N95 masks, which offer doctors, nurses and other staff more protection against infectious airborne particles than regular surgical masks.

“We are prepared to ride this out,” Coyne says.

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